With the news that Boise, Idaho-based St. Luke's Health System has been named one of the "Top 15 Health Systems" in the country for a third year in a row by Truven Health Analytics, I have reflected back on how we got here. It was not by accident. It was not without a lot of hard work. How did we do it?
I am not sure I even know all that had to happen at St. Luke's in order for us to achieve this top ranking among more than 300 health systems in the U.S. I do know some things that definitely contributed. 
Best Practices
1. Implementation of evidence-based best practices. Examples include our implementation across the health system of sepsis bundles early on, when we first began this journey, and more recently the Duke bundles for colon surgery to decrease surgical site infections. I also think some of our disease specialty certifications, such as becoming advanced primary stroke centers, have improved our performance and outcomes.
2. Standardization. Irrational variation is the enemy of quality and safety. Our relentless focus in trying to eliminate irrational variation has been a key to our success. The implementation of lean methodology, which we know as TEAMwork within St. Luke's, has been very helpful. We have hospitals with more than 400 beds and others in rural areas with 25 beds, and we know that we can't do everything exactly the same in these very different settings, but we don't use that as an excuse to do things differently just because of differences in size or location.
3. Culture. This element cannot be overstated. Before we started this journey, we thought we were great, even though the external data didn't always support that assessment. We have worked to overcome complacency and instill a desire to always get better, benchmarking ourselves and celebrating data showing those areas that are opportunities for improvement.
One of the best examples is our Project Zero. Our physicians, not settling for satisfactory benchmark performance for surgical site infections, embarked on a program to see if they could drive surgical site infections in orthopedics to zero. Many might have called that an impossible goal, but it was this kind of thinking that caused our physicians to look at air particle counts in the operating rooms and the impact of people moving in and out of the OR suites that led to changes in how we staff and supply those areas. It also caused us to revamp our patient skin prep prior to surgery. We have been able to reduce surgical site infections in our total knee and total hip replacement patients by half, and the most recent data suggests that the SSI rate continues to fall.
4. Engagement of our boards. I find those of us in healthcare make and accept excuses too readily. We will, for example, find a way to rationalize why handwashing might not happen all the time. It is much harder to explain that to community board members. We might also understand why a patient with a hip fracture on a weekend might wait until Monday for surgical correction — it doesn't make a lot of sense to our community board members. St. Luke's boards have set the expectations for quality improvement and dismiss excuses. There is nothing like having physicians discuss areas of opportunity before the board, the board asking the tough questions and then reinforcing subsequent positive improvements. This has been meaningful when we have stalled; we subsequently see tremendous improvements in those areas.
5. Engagement of our physicians. St. Luke's physicians have ample opportunity to lead quality improvement activities and initiatives without having to go through lengthy and cumbersome processes for administrative approval; they do not seek permission for every idea they have. We have identified physician champions for our quality and safety efforts and have structured physician leaders' schedules to ensure that these quality and safety efforts get the time and attention they need.
6. Use of data. We look at all the publicly available data and rating reports to focus our attention on those greatest areas of opportunity. Healthgrades, Truven Health Analytics and CMS data and reports have all been helpful in guiding us to areas in which we want to improve. St. Luke's also has partnered with a local analytics company on a product that allows all of our physicians to view data and reports easily and to compare their data with that of other physicians, which has promoted conversations and knowledge transfer and allowed physicians to improve independently.
7. Sharing of best practices. We have many pilots going on at the same time around our health system, as physicians and teams try out ideas to improve quality and safety outcomes. Once we see that something works, we socialize those new ideas and processes across the system. For example, our pulmonologists wanted to try early ambulation of patients while on ventilators in Boise. We tried it, determined how best to do it and measured the outcomes (fewer ventilator days, fewer ICU days, fewer ventilator-associated pneumonias, etc.). Once we knew it worked and how it could be done, we disseminated those practices and procedures to our other tertiary care hospitals.
Efficiency Gains
1. Length of stay. Among those strategies we have employed to minimize length of stay without compromising outcomes, readmissions (which have decreased, and in some cases, are among the best in the country) or patient satisfaction:
- The use of hospitalists, surgicalists, orthopedic hospitalists and laborists.
- The use of teleICU. This has led to decreased ICU days without any increase in total length of stay or increase in readmissions to the ICU. In addition, we have been able to extubate patients earlier and reduce ventilator days, identify risks and complications before they occur in our tertiary care centers and, in some instances, keep patients close to home in rural parts of our state where intensivists aren't available.
- Set expectations as to length of stay prior to surgery. Our joint replacement classes have been effective resources in this respect.
- Minimized complications. Avoiding preventable complications leads to shorter stays and lower costs. One example of a proactive measure to minimize complications is our pre-surgery clinic, staffed by hospitalists who see patients with medical comorbidities, so we can make sure each patient's medical condition is optimized prior to elective surgery.
2. Decreased Medicare spending. It is absolutely true that better quality of care results in lower costs, which is why many of the strategies above contribute to cost savings. Other measures we have implemented include:
- Center for Spine Wellness. The Dartmouth Atlas of Health Care has indicated that Boise has a disproportionately high rate of spine surgery. Our Center for Spine Wellness provides an opportunity for conservative management for patients other than those with clear-cut indications for surgical treatment. By having this specialized evaluation, we have significantly reduced the amount of imaging and the number of surgeries, and following the patients out for more than a year has indicated functional outcomes that validate a non-operative approach in the majority.
- Pulmonary Nodule Clinic. Oftentimes, pulmonary nodules are incidental findings, often in the emergency room. Typically, patients would be alerted to the finding with a referral weeks out to go see a specialist for evaluation, leaving patients and their families to worry for the intervening weeks. Our physicians realized that most of these patients do not need to be seen in order to determine next steps, if any. At St. Luke's, a multidisciplinary committee reviews the imaging studies, patients' information and health records, confers and makes recommendations, often saving patients from further imaging or biopsy procedures.
- Congestive Heart Failure Clinic. A cardiologist who is board-certified in heart failure leads this clinic, which makes great use of physician assistants and nurse practitioners. Five full days per week, three nurses and a social worker help coordinate patients discharged from the hospital, optimizing treatment regimens, seeing patients who are having exacerbations, educating patients and helping avoid readmissions through treatment in the clinic. The highest-risk patients are often co-managed with our cardiac rehab program. St. Luke's 30-day readmission and mortality rates are below the national average for all of our patients, but our 30-day readmission rate for these highest-risk patients who are followed in our clinic and cardiac rehab is 10.8 percent, which we believe to be among the lowest rates for patients with advanced heart failure in the country.
- Care coordination. We have put a program in place to review patients who likely need to go to a post-acute care setting. In our patient populations, post-acute care is a significant portion of the Medicare spending. We have worked with our local post-acute care providers and MEDPAR data processed through our analytics to identify the high-value, post-acute providers.
Other programs directed at increasing health and lowering costs have been highlighted on my blog over the past several years.
I cannot emphasize too strongly that the greatest initiatives and most innovative solutions have been implemented by physicians and staff working together around a common goal and are often started by an idea that one of them came up with. That is to say, they are grassroots initiatives. That is true at all levels; front-line staff are empowered and don't have to ask permission unless there are significant capital expenses associated with the effort. St. Luke's leadership is responsible for driving a culture that supports innovation and calculated risk-taking without fear, one that recognizes and rewards these efforts and that places quality and safety above all else.
David C. Pate, MD, JD, has served as president and CEO of St. Luke's Health System in Boise, Idaho, since September 2009. St. Luke's is the only Idaho-based nonprofit health system.